Tiwala, Gaining Trust to Recruit Filipino American Families: CARE-T2D Study

Abstract

Objective

Filipino Americans have greater risk for type 2 diabetes (T2D) and related complications compared to other Asian populations and non-Hispanic Whites. There are few diabetes intervention studies focused on Filipinos and limited evidence regarding the best recruitment strategies for this hard-to-reach population.

Methods

This article examined barriers and facilitators to recruitment of Filipino families for the “Caring for Asian Americans through Research and Education on T2D” (CARE-T2D) study, which took place in California from June 2018 through June 2019.

Results

Recruitment of 50 Filipino dyads (parent with T2D and adult child) were successfully met. Gaining trust through culturally tailored strategies was key in recruiting Filipino participants. Tiwala (gaining trust) strategies involved: 1) using Filipino staff as role models for research engagement and 2) incorporating narrative communications or “kuwentuhan” (Filipino cultural storytelling) with recruitment. Other facilitating strategies included in-person presentations at local colleges and organizations, Filipino community leaders’ support, snowball sampling, previous study participant listservs, and posting fliers on family/friends’ personal social media sites. Barriers to recruitment included research mistrust, confidentiality concerns, and risks of violating cultural values.

Conclusion

To our knowledge, this is the first study to recruit Filipino family dyads. Findings will inform researchers and clinicians on how best to recruit Filipino families in community health-related research and public health programs.

Introduction

Filipino Americans (Filipinos), one of the fastest growing US immigrant populations (4 million), are at higher risk for type 2 diabetes (T2D) compared to other Asians and non-Hispanic Whites.1,2 T2D prevalence among Filipinos is 13% compared to only 9% in the general US population. Moreover, Filipinos suffer from high rates of diabetes-related complications including hypertension, cardiovascular disease (CVD), stroke, and premature death.3-5 Despite these disparities, there is a paucity in preventive health research for Filipinos.6,7 It is imperative to identify effective diabetes interventions that reduce T2D prevalence and related complications among Filipinos.

Family support and culturally tailoring are two effective intervention strategies for Asian immigrants that improve diabetes self-management (eg, glycemic control, medication adherence) and reduce T2D risks and complications.8-10 Studies on family support dynamics for diabetes self-management have focused on multiple minorities (African Americans, Hispanics, Chinese, Southeast Asians, and Pacific Islanders), yet few have focused on Filipinos.4,6,11,12 Culturally tailored lifestyle interventions have been effective promoting research engagement among other diverse populations.13 However, culturally tailored interventions focused on Asian Americans are limited.6,14

Therefore, we conducted the Caring for Asian Americans through Research and Education on Type 2 Diabetes (CARE-T2D), a preliminary survey study including individual semi-structured interviews. The objective of our study was to understand family support dynamics for diabetes self-management within family dyads (parents with T2D and their adult child). The recruitment goal was 50 Chinese and 50 Filipino family dyads. Findings will inform the development of a culturally tailored intervention to promote family communication/interactions that support parents’ diabetes self-management.

Due to limited Filipino health research, data are scant on barriers and facilitators for recruiting Filipinos.2,15 Although often perceived as friendly and family/community-oriented, Filipinos can be an insular and hard-to-reach population.16 Cultural barriers such as mistrust of Western medicine/research, diabetes stigma, and immigration fears (deportation) often discourage research participation.17-19

Thus, this article focuses on Filipino recruitment strategies, facilitators and barriers for research participation, and lessons learned. Results of the Chinese recruitment strategies and results of this study are reported in manuscripts under preparation for publication.

Theoretical Framework

The dual frameworks of social cognitive theory (SCT) and narrative communication (storytelling) guided recruitment strategy selection and implementation.20,21 SCT posits behaviors are learned and reproduced from observing trusted role models (eg, community and church leaders) and from environmental feedback. Storytelling involves personal or secondhand anecdotes that are relatable or reflect shared cultural experiences.21 Such stories can form connections or elicit certain target behaviors from an audience. For example, Black women breast cancer survivors in the Witness Project Study gave personal narratives emphasizing the importance of early breast cancer screening.22 CARE-T2D study recruitment strategies employed storytelling or kuwentuhan (Filipino cultural storytelling) and tiwala (gaining trust) to connect with potential participants.23 Specifically, CARE-T2D Filipino research staff role modeled research participation and shared stories of supporting parents with T2D.

Methods

Study Design

The CARE-T2D was a preliminary exploratory study using mixed methods: 1) quantitative cross-sectional online surveys; and 2) qualitative semi-structured interviews. Secure institutional web-based applications were used for: 1) online surveys (Qualtrics.com); and 2) semi-structured online interviews (Zoom video conferencing-zoom.us). Participants used personal computers, tablets, or smartphones to complete surveys and interviews.

Filipino Participants and Setting

Recruitment goal was 50 Filipino family dyads (parent and adult child). All potential participants were prescreened for eligibility via telephone interviews. Inclusion criteria included: self-identified as Filipino; male or female; parent aged ≥45 years with T2D; adult child aged ≥18 years without T2D; California resident; intra-dyad communication within the last 6 months; able to read and comprehend English, with access to computer, tablet, or smartphone. Exclusion criteria were: adult child with diabetes (any type); no or inconsistent communication between parent and child; or interest only in monetary compensation. Inclusion/exclusion criteria were based on the study’s aim to explore how cultural issues (eg, diabetes stigma and deference to parental authority) impacted family dynamics and communications, particularly among parents with T2D and their children with limited diabetes knowledge.19,24 Criteria were limited to English-speakers based on the Pew Research Center report that among Filipinos (aged ≥5 years, foreign- and US-born) English proficiency was 84%.25

CARE-T2D was conducted in California from June 2018 through June 2019. Institutional Review Board approval was obtained from San Francisco State University. Participant informed consent was obtained prior to study participation. Compensation was a $20 gift card for survey completion and a $50 gift card for interview participation. Informed consent was obtained from all participants included in the study. Informed consent was collected prior to completion of telephone screenings, surveys, and semi-structured interviews (when applicable).

Recruitment Implementation

All staff were trained by principal investigators on recruitment, study protocols, data collection (assisting with surveys and qualitative interviews) and management (using secure database servers). Local nurses from the Philippine Nurses Association of Northern California (PNANC) volunteered as interpreters, as needed, for participant interviews.

To impart empathy and encourage participation, Filipino staff served as culturally congruent community role models. Staff were selected with similar socio-demographics as the target population (eg, immigration status, ethnicity, socioeconomic status, age, language). One PI was a first-generation Filipina researcher and expert on Philippine culture and diabetes. Among staff, one was a first-generation bilingual Filipina nurse, another was a second-generation Filipina public health worker with type 1 diabetes, and a third was a second-generation bilingual Filipina university educator. All staff had personal experience supporting parents with T2D.

Recruitment strategies included: cultural tailoring; role modeling and narrative communication; social media posts; word-of-mouth referrals (family and friends, snowball sampling); past Filipino study participants; and community recruitment at colleges, local organizations, church health fairs, and cultural events. These strategies are described below.

Cultural Tailoring

Prior to recruitment, study materials were culturally adapted. Study flyers and social media pages were tailored using relevant symbols and icons (eg, Philippine flag, Golden Gate Bridge, radiant sun, and red, gold, and blue colors from Philippine flag). Photos of Filipino families were also used on flyers and social media pages. Study materials and tools were vetted for cultural appropriateness by Filipino PIs and staff, and volunteer nurses.

Filipino staff conducted telephone screenings and assisted participants with the online surveys and interviews. Upon participant request, bi-lingual Filipino staff administered surveys and interviews. If needed, bilingual volunteer PNANC nurses (Tagalog/Ilocano-Philippine languages) were also available as interpreters.

Role Modeling and Kuwentuhan (Filipino Storytelling)

During recruitment, staff behaved as role models exemplifying research participation. Staff also employed kuwentuhan by sharing experiences of supporting parents with T2D.21-23 Stories included driving parents to clinic visits, assisting with medications, and monitoring diet and exercise. Participants were also encouraged to share their stories. These strategies helped engender tiwala (gain trust) and connect with potential participants, mitigate discomfort, and emphasized the importance of research participation to improve Filipino health. These strategies were incorporated with other recruitment efforts (eg, presentations at colleges and community events, engaging community leaders, telephone screenings, and follow-up calls).

Social Media

Recruitment flyers were posted on the CARE-T2D social media sites (Facebook and Craigslist) and staff’s, friends’, and families’ personal Facebook and Instagram sites. Google phone and email were used to monitor communications with potential participants. Community leaders, organizations, and academic institutions posted study flyers on their listservs.

Referrals, Word of Mouth, and Snowball Sampling

Filipino community leaders (political, educational, health care, and organizational) were enlisted to participate in the study and refer potential participants. Using snowball sampling, participants were asked to refer potential participants. Previous Filipino study participants were also contacted.

Community Recruitment

Staff posted and distributed flyers, and enrolled potential participants at hospitals, health fairs, shopping malls, Filipino events (San Francisco Pistahan and Kasayahan sa Daly City) and local colleges (class announcements and recruitment tables). Presentations were given at Rotary International, Lion’s Club, and PNANC meetings.

Data Collection

Potential participants received follow-up calls and completed telephone screenings for eligibility. If a parent and adult child dyad were eligible, each was enrolled and received a study ID. Participants were emailed an online survey link to complete within one week. Staff were available to assist participants requesting help using digital technology.

A database spreadsheet tracked participants’ contact information, recruitment site, telephone screening status, surveys, interviews, and contact attempts. Participants with incomplete screenings or surveys were called, texted, or emailed reminders. After three contact attempts, unresponsive participants were deemed lost to follow-up.

Data Analysis

Figure 1 displays the consort diagram with participant tallies for each study stage: 1) potential participants contacted; 2) completed telephone screenings; 3) eligible and excluded participants; and 4) enrolled dyads. Telephone screening data were recorded along with reasons potential participants were excluded or declined to participate, share contact information for dyad member, or complete surveys. Figure 2 presents tallies of enrolled participants for each recruitment strategy, ranked by number of enrolled parents and adult children, from most to least successful strategy.

Figure 1. Consort Diagram.

Figure 2. Enrolled participants by recruitment strategies.

Results

Recruitment goal of 50 Filipino dyads was achieved. Out of 310 potential participants, only 135 completed the telephone screening. Of these 135, 129 were eligible and enrolled, but only 105 completed the surveys. Five participants (3 parents and 2 adult children) completed the surveys but were not counted because their family dyad was incomplete (lacked a parent or adult child). Twenty-four enrolled participants declined to complete the survey. Figure 1 provides reasons for incomplete surveys as well as reasons potential participants were excluded or declined to participate. The reasons included: mistrust, diabetes stigma, family concerns, time constraints, low-English literacy, and digital technology difficulties.

Table 1 reports participants’ socio-demographic characteristics. Overall, most participants were female 63% (n=63/100). Overall, mean age was 50.9 SD+18.2 years, while mean age for parents was 67.1 SD+7.5 years and adult children was 34.6 SD+8.9 years. Parents were primarily immigrants living in the United States >10 years (92%), whereas adult children were primarily native born (70%). Most participants were highly educated with either a bachelor’s degree (40%) or had some graduate school attendance or degree (30%). Most parents were retired (52%), while most adult children worked full-time (84%). Overall, participants perceived their health as good or excellent (87%).

Table 1. CARE-T2D Filipino socio-demographics.

Variables	Overall, N=100	Parents + T2D, n=50	Adult Child, n=50
Gender
Male	37	20	17
Female	63	30	33
Mean Age
Male, years (SD)	51.7 (+20.0)	68.5 (+7.8)	32.0 (+7.9)
Female, years (SD)	50.3 (+17.3)	66.1 (+7.3)	36.0 (+9.2)
Average, years (SD)	50.9 (+18.2)	67.1 (+7.5)	34.6 (+8.9)
Race/Ethnicity
Filipino only	91	48	43
Filipino + other race	9	2	7
Language (English)	100 (able to speak comprehend and read)
Marital status
Never married	22	0	22
Married/cohabitating	60	35	25
Divorced	10	7	3
Widowed	8	8	0
Years lived in US
Native born	39	4	35
5 - <10 years	1	0	1
≥10 years	60	46	14
Education
High school grad/GED	6	5	1
Some college	15	7	8
Associate degree	7	2	5
Bachelor’s degree	40	17	23
Graduate school/degree	30	18	12
Decline to answer	2	1	1
Employment status
Employed full time	61	19	42
Unemployed /looking	3	0	3
Self-employed	4	4	0
Retired	26	26	0
Homemaker	1	0	1
Student	4	0	4
Disabled	1	1	---
Health status
1= very poor to 4=good	13	11	2
5 ≥ good or 7 = excellent	87	39	48

SD = standard deviation; GED= general education development

Enhancing Facilitators and Addressing Barriers

The research team sought ways to capitalize on facilitators and address barriers for recruitment. Table 2 lists the recruitment barriers encountered, and the strategies implemented by staff to mitigate those barriers to participation and are briefly described below.

Table 2. Facilitators and barriers to recruitment.

Facilitators	Barriers	Strategies to Address Barriers
Tiwala (gaining trust): Ethnically congruent Filipino staff role modeled research participation.	Potential violation of Filipino cultural values: Pakikisama (family harmony); Utang na loob (debt and gratitude to parents)	Family-oriented events: Staff capitalized on opportunities for in-person interactions with families by targeting local colleges, family-oriented community events, and local health fairs.
Kuwentuhan: Staff shared personal stories of supporting family members to gain participants’ tiwala (trust); stories addressed cultural values (ie, pakikisama, utang na loob, and machismo)	Reluctance to ask parent or child: Perception of burden, machismo (pride), stigma of diabetes, desire to maintain self-control, lack of awareness of parent’s health status, unfamiliar with caregiving role (n=91)	Filipino language translation: bilingual Filipino staff and volunteer nurses served as translators (verbal screenings, surveys, and assistance by phone)
Word-of-mouth referrals: Family and friends, snowball sampling, past Filipino studies.	Cultural distrust: Concerns about immigration status, deportation, and identity theft. (n=20)	Presentations included clear, easy to understand information; Informed consent is multiple Philippine dialects
Trusted Filipino community leaders: Introduced research team to community at meetings and gatherings; referred potential dyads that met eligibility criteria.	Impersonal social media ads: Respondents from social media sites were only interested in monetary incentives, making them ineligible to participate. (n=20)	Social media advertisements: Flyers and advertisements were posted by staff members’ family/friends and community leaders’ personal social media accounts
	Time constraints: lack of time due to family and work commitments (n=40)	Flexible scheduling: assistance to complete screenings, surveys, and interviews throughout week (day or evening); staff assistance via phone, or in person at the recruitment site
	Low English literacy: screenings and surveys were only available in English (n=10)	College campuses: Recruitment tables were erected, and study announcements were delivered in classrooms.

Tiwala - Gaining Trust

Tiwala with Filipinos was essential to facilitate recruitment. With Kuwentuhan, Filipino staff shared personal stories to help connect with potential participants and emphasize the importance of research participation. After experiencing kuwentuhan, many participants expressed altruistic sentiments to help improve Filipino community health and support parents with T2D.

Figure 2 displays several effective recruitment strategies including: word of mouth referrals (n=34) and Filipino community organization meetings (n=24); in-person presentations and recruitment tables at college campuses (n=24); and contacting previous Filipino study participants (n=17). Social media was the least effective recruitment strategy (n=8).

Addressing Recruitment Barriers

Major barriers to recruitment were maintaining family harmony, time constraints, and research distrust due to immigration concerns (eg, deportation and loss of confidentiality or personal identification information). Other barriers included impersonal social media ads, low-English literacy, and digital technology difficulties.

Disruption of Family Harmony

Difficulty recruiting complete family dyads was due primarily to disrupting pakikisama (familial harmony).24 For example, parents were reluctant to ask their children to participate due to: 1) fear of burdening them; 2) machismo (pride or desire to maintain self-control); and 3) stigma of diabetes.19 Furthermore, children were reluctant to ask parents to participate because they lacked knowledge of parent’s health status or familiarity with the care-giver role and feared violating utang na loob (cultural value of debt and gratitude to parents).24 Thus, although potential participants desired to help improve Filipino health outcomes, preserving familial harmony took precedence over study participation. Pakikisama, utang na loob, and machismo were also cited as the reasons for not completing surveys or declining to ask parent or adult child to participate.19,24

To address these cultural barriers and facilitate recruitment, staff applied in-person interactions, particularly with Filipino college students and families at Filipino community events and health fairs. Recruitment tables were placed at student centers and in-person announcements were made in classrooms. In-person presentations discussed how research participation contributes to improving Filipino community health, while kuwentuhan addressed mitigating fears of disrupting the cultural values of pakikisama, utang na loob and machismo (family dyads = 10).23,24

Time Constraints

Many Filipinos declined to participate due to time constraints (work or family responsibilities). To address this barrier and accommodate participant schedules, staff: 1) during recruitment, discussed expected time requirements (survey=20 minutes, interview=1 hour); 2) offered flexible study appointments (day or evenings including weekends); and 3) offered assistance to complete screenings, surveys, and interviews.

Social Media Advertising

Social media flyers and ads posted on Facebook and Craigslist sites were recruitment barriers because most respondents to this strategy were interested only in monetary incentives, and thus, ineligible. Moreover, impersonal online CARE-T2D Facebook and Craigslist ads broadcasted throughout northern California were largely ignored by the Filipino community.

To address these impersonal social media barriers, study flyers and ads were instead posted on families’ and friends’ personal social media sites (Facebook and Instagram). Filipino community leaders and organization members were also asked to post study flyers on their personal social media sites. These strategies recruited four family dyads.

Low-English Literacy

Low-English literacy was a barrier to recruitment because study eligibility required English proficiency. Telephone screenings and surveys were only offered in English. To address this barrier, multi-lingual Filipino staff and volunteer nurses offered verbal telephone screenings and surveys in Tagalog and/or Ilocano Philippine dialects. Multi-lingual staff were also available to conduct participant screenings at community events and health fairs. Only two enrolled dyads requested an interpreter.

Digital Technology

Access to digital technology was a barrier to recruitment. Four enrolled participants dropped out of the study because they could not access a computer/tablet or had difficulty using their smartphone and declined staff assistance.

To address this barrier, potential participants were given the option to immediately complete the telephone screening with assistance at recruitment sites, and if eligible, immediately complete surveys, or schedule staff assistance at their convenience.

Research Mistrust

Mistrust in research due to immigration fears of deportation (n= 10) and/or loss of personal identification information and confidentiality (n= 10) were major concerns. To address these barriers, study presentations included clear, easy-to-understand information about the CARE-T2D Study, how research could help to improve Filipino health outcomes, and why Filipino participation was needed. If low-English literacy was a concern, the study consent form was explained in easy-to-understand English or in either Tagalog or Ilocano. Participants were reassured that immigration information was not required, or shared; all personal identifying information was confidential, and stored at secure institutional locations where only authorized research staff had access. Typically, after presentations and follow-up discussions, Filipinos were willing to participate. Because cultural tailoring and kuwentuhan promoted tiwala, they were also incorporated into other strategies (telephone screenings, in-person presentations, and friend/family social media) to increase their effectiveness in connecting with Filipinos.23

Discussion

There is limited information on effective Filipino recruitment strategies because they are underrepresented in research and often a hard-to-reach population. This article describes barriers and facilitators for recruiting Filipino family dyads (parent and adult child) in the CARE-T2D study. To our knowledge, this is the first study to enroll Filipino American family dyads. Although there were recruiting challenges, the recruitment goal (50 Filipino family dyads) was met.

Lessons Learned

The dual theoretical frameworks of social cognitive theory emphasizing role models for learning behaviors and narrative communication (storytelling) were used to guide the recruitment strategies.20,21 Therefore, recruitment strategies incorporated culturally congruent Filipino staff to role model (research participation) and applied kuwentuhan (Filipino storytelling about supporting parents with T2D).23

Previous studies identified trust as an essential component for engaging Filipinos in research.26,27 These strategies helped promote tiwala (gaining trust) among Filipinos and emphasized the importance of research participation. Tiwala, may have reduced Filipino discomfort, and may have encouraged research participation, thereby prompting altruistic sentiments that may contribute to improving community health.

There were multiple barriers to recruitment. Historically, Filipinos’ mistrust toward research has been a barrier, depending on varying levels of acculturation, eg, immigration status, resident duration, and nativity.28 Among recent and first-generation immigrants, mistrust is prevalent toward US immigration enforcement and Western medicine.17,18,29 This was evident when recruiting at local community events. To address this barrier, cultural tailored strategies were applied. Culturally congruent Filipino research staff were used, community leaders were engaged, and kuwentuhan was applied to promote tiwala among Filipinos.23,24 Community leaders also shared their listservs to refer potential participants and offered feedback on their successful recruitment strategies.

Cultural concerns for disrupting family harmony were major barriers to recruiting dyads. including pakikisama, utang na loob, and machismo.24 Pakikisama revealed a reluctance among adult children to ask parents to participate for fear of violating familial boundaries and disrespect for parental authority.30 The children also feared stigmatizing their parents with T2D or were themselves embarrassed due to limited knowledge of how to provide caregiving support for parents.19 To overcome these barriers, in-person recruitment strategies were employed (eg, presentations at colleges, and community organizations and events). Recruitment of Filipinos at college campuses was successful, possibly because many student participants were native born, living at home, highly acculturated, and with some knowledge of both research and diabetes. Thus, these participants were prepared to encourage their parents to participate.

CARE-T2D barriers and facilitators were similar to previous studies with Asian American/Native Hawaiian Pacific Islanders (AA/NHPI).31-34 Among Chinese and Korean American breast cancer survivors, similar barriers to study participation included distrust of research due to immigration status,31 time constraints due to work commitments and caregiving obligations to children or parents.32 Similar to kuwentuhan, a storytelling approach was used to gain AA/NHPI trust. Other successful strategies for Native Hawaiians include community-academic partnerships, with culturally congruent community members assisting with recruitment at community centers and through word of mouth.33,34

Study Limitations

There were several potential study limitations. Participants were limited to Filipino residents of California. Participants were recruited using personal approaches (ie, personal social media postings and referrals) that may have led to a social desirability response bias.35 Eligibility required English literacy and digital technology access that precluded non-English speakers, those with low-digital technology proficiency, and certain socio-economic populations. This recruited sample is skewed with highly educated, medically insured participants. Therefore, study findings may not be generalizable to broader Filipino populations.

Recommendations for Future Studies

Social Media Advertising

Evidence indicates social media effectiveness for health research recruitment is growing.26,36,37 Research with African American women found that, in comparison to traditional recruitment methods (eg, flyers, health fairs), social media (Facebook and Craigslist) was an effective strategy to reach potential participants, although proportionately smaller numbers enrolled.37 Similarly, impersonal CARE-T2D’s social media ads were largely ignored by Filipinos, possibly due to culture and mistrust, thus limiting participation. When using social media for recruitment, future studies should use personal approaches (eg, using community members and family/friends’ personal social media sites for posting study flyers and ads).

A personal approach could also be used to leverage kuwentuhan for recruitment.23 For example, Filipino community leaders and members could share personal stories that address cultural values and the importance of research participation for health. Prior research with Filipino parents indicated that first-hand testimonials were the most effective approach for recruitment.28 One Filipino study utilized a culturally tailored video featuring past participants’ testimonials to successfully recruit new families in a parenting study.38 Video-taped testimonials can humanize this social media tool to mitigate distrust towards research engagement.

Participant Accommodations

Culturally adapting recruitment strategies should include flexible scheduling and digital technology assistance, especially with older participants. Printed study materials in Philippine dialects can also help mitigate language barriers, particularly among first-generation immigrants with low-English literacy. Including culturally congruent bilingual Filipino staff and community members can promote research participation.15,26 Future studies should incorporate these cultural adaptions to reduce barriers to recruitment and limit participant dropout.

Conclusion

This study demonstrated that a hard-to-reach Filipino population can be recruited through effective recruitment strategies that facilitate research participation by Filipino Americans. To our knowledge, this is the first study to recruit Filipino family dyads. Previous dyadic studies focused on family-based interventions with Latino and married/partnered dyads.39,40 This study informs health care providers and researchers on how best to recruit Filipino Americans by incorporating culturally congruent Filipino staff as role models and applying kuwentuhan (storytelling) and tiwala (gain trust) to promote research participation. Understanding the barriers and facilitators for recruiting Filipinos can further inform researchers and health care providers in designing culturally appropriate public health programs that will promote health equity and improve outcomes in this underserved high-risk population.